Sentinel lymph node biopsy in oral cancer: validation of technique and clinical implications of added oblique planar lymphoscintigraphy and/or tomography

Purpose: To validate lymphatic mapping combined with sentinel lymph node biopsy as a staging procedure, and to evaluate the possible clinical implications of added oblique lymphoscintigraphy and/or tomography and test the intra- and interobserver reproducibility of lymphoscintigraphy.

Material and Methods: Forty patients (17 F and 23 M, aged 32-90) with 24 T1 and 16 T2 squamous cell carcinoma of the oral cavity. Planar lymphoscintigraphy, emission and transmission tomography were performed. Detection and excision of the sentinel nodes were guided by a gamma probe. The sentinel nodes were step-sectioning and stained with hematoxylin and eosin and cytokeratin (CK 1). Histology and follow-up were used as “gold standard”. Tumor location, number of sentinel lymph nodes, metastasis, and recurrences were registered. Two observers evaluated the lymphoscintigraphic images to assess the inter-rater agreement.

Results: Eleven (28%) patients were upstaged. The sentinel lymph node identification rate was 97.5%. Sentinel lymph node biopsy significantly differentiated between patients with or without lymph node metastasis (P = 0.001). Lymphatic mapping revealed 124 hotspots and 144 hot lymph nodes were removed by sentinel lymph node biopsy. Three patients developed a lymph node recurrence close to the primary tumor site during follow-up. Added oblique lymphoscintigraphic images and/or tomography revealed extra hotspots in 15/40 (38%) patients. In 4/40 (10%), extra contralateral hotspots were detected.

Conclusion: Sentinel lymph node biopsy upstaged 28% of the patients. Sentinel lymph nodes close to the primary tumor were difficult to find. Added oblique planar images and/or tomographic images revealed extra clinical relevant hotspots in 38% of patients. Reproducibility proved excellent.     

Sentinel lymph node detection with large human serum albumin colloid particles in breast cancer

Detection of metastatic involvement of lymph nodes is essential for management and prognostic evaluation in breast cancer patients. The success of lymphatic mapping depends on identifying the sentinel lymph node(s) draining the primary tumour. However, when mapping is performed with a radiocolloidal agent, the number of hot lymph nodes varies with the agent and its size, among other factors. In this study, we evaluated prospectively the detection rate of sentinel lymph nodes in breast cancer when injecting large particles (100-600 nm) of human serum albumin colloids (Senti-Scint). In 128 consecutive breast cancer patients without palpable lymph nodes, pre-operative static lymphoscintigraphic mapping of the breast was performed after subcutaneous injection of 15 MBq of the radiocolloid. Lymphoscintigrahic results were compared with intra-operative surgical gamma detection probe and blue dye mapping data. Pre-operative lymphoscintigraphy and surgical gamma detection probe both correctly detected 203 sentinel lymph nodes in 122/128 patients (95%), while blue dye mapping showed only 183 sentinel lymph nodes in 82% of the patients. Only one or two sentinel lymph nodes were identified in each patient, which allowed the surgeon easily to find the sentinel lymph node(s) intra-operatively. In conclusion, lymphoscintigraphy with large particles of human serum albumin colloids is a helpful and reliable procedure for the surgical management of breast cancer.     

Evaluation of mammary lymphoscintigraphy by a single intratumoral injection for sentinel node identification.

The aim of this study was to evaluate the findings of mammary lymphoscintigraphy by a single intratumoral injection in 150 patients with breast carcinoma: 100 patients (group A) investigated in the validation phase of the study and 50 (group B) studied after the tracer dose was optimized. METHODS: Immediately after injection of 99mTc-nanocolloid using a 25-gauge needle and a 0.2-mL volume, simultaneous anterior and lateral images were acquired with a dual-head gamma camera during 20 min followed by sequential static anterior and prone lateral breast images after 30 min and after 2 and 4 h. 57Co-assisted skin marking defined the sentinel node location for subsequent gamma probe, blue dye-guided sentinel node biopsy. RESULTS: In group A (mean dose, 61.6 MBq; range, 42-88 MBq) scintigraphy revealed lymph nodes in 83 patients (83%), with an increase in the rate of visualization from 72% for the first 40 patients to 90% for the last 60; patient age (P = 0.01) and administered tracer dose (P = 0.04) were found to be significant factors for visualization, with optimal results obtained from doses higher than 65 MBq. Lymph nodes were visible in 34 patients (41%) during the first 30 min after injection, whereas in 49 patients appearance occurred at 2-4 h. A total of 97 lymphatic basins were visualized (80 axillary, 3 clavicular, 14 internal mammary). In group B (mean dose, 90.8 MBq; range, 68-124 MBq), the visualization rate was 94%, with early lymph node appearance in 27 patients (57%) and a total of 53 basins (45 axillary, 8 internal mammary). In combination with intraoperative blue dye mapping and y probing, the identification rate increased to 90% in group A and 98% in group B. Prone lateral images contributed to identification of intramammary lymph nodes in a total of 14 patients and axillary nodes close to the injection site in 8 other patients. CONCLUSION: Mammary lymphoscintigraphy by single intratumoral injection is a valid method for lymphatic mapping and identification of both axillary and nonaxillary sentinel nodes. Lymph node visualization appears to be improved with higher tracer doses. The compactness of the injection site enables high-quality additional lateral images that can depict intramammary or axillary lymph nodes adjacent to the injection site.     

Alternative lymphatic pathway after previous axillary node dissection in recurrent/primary breast cancer

OBJECTIVES: The sentinel lymph node approach has almost become the standard procedure of choice in the management of patients with early breast cancer. The status of sentinel nodes, whether or not pathologically involved by cancer cells, represents those of the axillary nodes with a negative predictive value of almost 100%. If the axillary lymphatic nodal drainage is altered, alternative lymphatic pathways and accordingly sentinel node location will be changed. METHODS: In this article, 4 patients are presented, 3 with recurrent breast cancer who had already undergone lumpectomy, axillary node dissection, and radiotherapy in the past and 1 with primary breast cancer after surgical removal of a malignant melanoma on her back and had axillary node dissection on the same side as the breast cancer. These patients underwent lymphoscintigraphy followed by sentinel node localization using the gamma probe and also blue dye injection during surgery. RESULTS: All patients showed alternate lymphatic pathways, 1 had an ipsilateral internal mammary node and crossed lymphatics to a contralateral axillary node, 2 had intramammary sentinel nodes, and 1 had an internal mammary on the same side. Pathologic examination of the intramammary and contralateral sentinel nodes were negative for metastases. Internal mammary sentinel nodes were not biopsied. CONCLUSION: We feel that sentinel node lymphoscintigraphy should be done even in patients who have altered lymphatic pathways resulting from previous axillary node dissection. It allows identifying and biopsy of the sentinel node at its new unpredicted location.     

Comparison of different injection sites of radionuclide for sentinel lymph node detection in breast cancer: single institution experience

BACKGROUND: There are still ongoing controversies about several aspects of lymphatic mapping and sentinel lymph node biopsy for breast cancer, including injection site of radioisotope and blue dye. This study aims to evaluate the success rate of different radiocolloid injection techniques in the detection of sentinel lymph nodes (SLN) in early breast cancer. STUDY DESIGN: One hundred ninety-two women with early breast cancer were included. For SLN mapping with lymphoscintigraphy (LSG), 5 different injections were used. Group A (36 patients) had 4 peritumoral (PT), group B (n = 36) had 1 subdermal (SD) injection of Tc-99m rhenium sulfide colloid over the tumor quadrant. Group C (59 patients) had 1 PT and 1 SD combined injections. In group D (56 patients), lymphatic mapping was performed with 2 intradermal periareolar (ID-PA) injections. In group E (n = 41), 2 ID-PA and 1 PT combined injections were performed. Early dynamic and delayed images were obtained. A surgical gamma probe was used to explore the SLNs. Surgical specimens were evaluated histopathologically. The SLN identification rate, false negative rate, and comparison of groups were evaluated by statistical methods. RESULTS: The SLN identification rate by LSG in groups A, B, C, D, and E were 72%; 92%, 93.2%, 98%, and 95%, respectively. The highest detection rates for the axilla (98%) and mammary internal (MI) drainage (22%) were obtained with ID-PA injections and a peritumoral injection, respectively. Seventy of 192 patients (36.4%) had positive axillary lymph nodes. The only statistically significant difference was between the PT and SD injection groups in axillary SLN identification rate by LSG (P = 0.016). CONCLUSION: The success rate was superior with intradermal periareolar injection compared with PT and SD injection to visualize the axillary SLN. However, PT deep injection combined with ID-PA injections may be more favorable to demonstrate the primary internal mammary (IM) lymphatic drainage.     

Scintigraphic sentinel node detection in breast cancer patients: paired and blinded comparison of 99mTc dextran 500 and 99mTc phytate

BACKGROUND: Breast cancer surgery has evolved towards minimizing morbidity, maximizing cure rates and stratifying treatments according to disease stage. Sentinel lymph node biopsy is becoming standard practice in most centres. However, no standard radiopharmaceutical exists. OBJECTIVES: To blindly compare 99mTc dextran 500 and 99mTc phytate in the scintigraphic detection of sentinel lymph nodes. Endpoints were the detection of axillary or internal mammary lymph nodes, number of lymph nodes detected, detectability in the first versus the second hour of evaluation and the relationship between rate of detection and age or body mass index. METHODS: Forty-six patients with histological diagnosis of early breast cancer, without previous surgical treatment, were enrolled in our study. Each patient underwent lymphoscintigraphy twice: on one day with 99mTc dextran 500 and on another day with 99mTc phytate. Images were acquired 1 h and 2 h after tracer administration. RESULTS: Eighty-eight lymphoscintigraphic studies were performed in 44 patients. On the first image (taken at 1 h), 34 patients from the 99mTc dextran group showed sentinel nodes compared with 28 positive examinations using 99mTc phytate (P = 0.113). On the second image (taken at 2 h) 39 patients from the 99mTc dextran group showed positive results compared to 30 positive examinations using 99mTc phytate (P = 0.036). There was no statistically significant correlation between the body mass index or age and the result of the lymphoscintigraphy. CONCLUSION: 99mTc dextran 500 is better than 99mTc phytate for use in a 2 h interval scintigraphic protocol because it demonstrates the sentinel node in a significantly higher number of patients and also showed more lymph nodes suitable for pathological examination.     

乳腺癌前哨淋巴结核素显像新进展

乳腺癌是全球女性发病率最高的恶性肿瘤, 为保证患者的生存率、减少术后并发症, 20世纪90年代用"腋窝前哨淋巴结活检术取代腋窝淋巴结清扫"的观点被提出并逐渐发展成为乳腺癌患者保乳术的常规方法。除腋窝前哨淋巴结外, 内乳前哨淋巴结的重要性同样不容忽视, 但是否将其作为前哨淋巴结活检的对象仍存在争议。面对目前形势, 核医学工作者做了大量研究, 在保证腋窝前哨淋巴结高显示率的同时尽可能提高内乳前哨淋巴结的显示率。笔者对近十年来国内外研究者在乳腺癌前哨淋巴结核素显像中的核素示踪剂、注射技术、显像仪器等方面的最新进展进行综述。     

Technical aspects of sentinel node lymphoscintigraphy for breast cancer.

OBJECTIVE: A significant morbidity risk is associated with axillary nodal dissections for breast cancer. Many treatment decisions are based on axillary nodal status. Lymphatic mapping and sentinel node biopsy have been investigated to determine if the histology of the sentinel node reflects the remaining lymph node basin. We describe the technical aspects of sentinel node lymphoscintigraphy for breast cancer. METHODS: Ninety-three patients had lymphoscintigraphy for breast cancer. Patients with palpable lesions had 4 concentric injections around the site and lesions requiring localization had injections made through tubing connected to the localizing wire introducer needle. Immediate static images were acquired and the sentinel node was marked for surgery. Marks were reverified using a handheld gamma probe. RESULTS: Lymph nodes were visualized by lymphoscintigraphy in 87% of cases. Time to visualization of lymph nodes ranged from 1-120 min with a mean of 28 min. An average of 1.5 nodes were visualized. The overall success rate for identifying the sentinel node at time of surgery was 85%. CONCLUSION: We conclude that lymphoscintigraphy for breast cancer is a detailed procedure that requires coordination with radiology and surgery teams to ensure proper identification of sentinel lymph nodes.     

Fusion lymphoscintigraphy with a 24-hour Tc-99m MDP bone scan for sentinel lymph node detection and imaging

A 62-year-old woman with right breast carcinoma who had a breast biopsy 3 weeks earlier was referred for a whole-body Tc-99m MDP bone scan to identify possible osseous metastases. Twenty-four hours later, she underwent lymphoscintigraphy using four peritumoral injections of 250 microCi filtered Tc-99m sulfur colloid of 0.22 microm each. The lymphoscintigraphic images showed good delineation of three right axillary lymph nodes in relation to the rib cage. Performing a bone scan just before lymphoscintigraphy for sentinel node detection may help the surgeon to identify sentinel lymph nodes. This is more anatomically precise than using a flood source to delineate body contour. A Tc-99m MDP bone scan followed by lymphoscintigraphy should be considered in patients with breast carcinoma who will have both bone imaging and lymphoscintigraphy.     

Clinically node-negative breast cancer, internal mammary lymph nodes, and sentinel lymph node biopsy

We report 2 cases demonstrating that localization of internal mammary (IM) sentinel lymph nodes with lymphoscintigraphy using peritumoral injection of Tc-99m antimony sulfide colloid, followed by resection using minimal access surgery, can reveal nodal metastatic disease in patients with clinically node-negative breast cancer when axillary sentinel nodes are not affected by metastatic disease. When this is found, it changes staging and can affect prognosis and treatment. These cases confirm that the technique used is sampling true sentinel IM nodes, that is nodes that receive direct lymph flow from the breast cancer, and confirm the importance of sampling IM sentinel lymph nodes. Unless techniques are used that are specifically designed to identify IM node drainage from the breast cancer site itself, with subsequent directed surgical removal of sentinel IM nodes, some patients with breast cancer will not be staged correctly.     

Factors affecting sentinel node localization during preoperative breast lymphoscintigraphy.

Variable success rates for identifying axillary (AX) sentinel nodes in breast cancer patients using preoperative lymphoscintigraphy have been reported. We evaluated the effects of age, weight, breast size, method of biopsy, interval after biopsy, and imaging view on the success of sentinel node identification and on the kinetics of radiopharmaceutical migration. METHODS: Preoperative breast lymphoscintigraphy was performed in consecutive breast cancer patients from February 1998 to December 1998. The ipsilateral shoulder was elevated on a foam wedge and the arm was abducted and elevated overhead. Imaging using this modified oblique view of the axilla (MOVA) started immediately after peritumoral injection of Millipore-filtered 99mTc-sulfur colloid and continued until AX sentinel nodes were identified. Anterior views were obtained after MOVA. AX, internal mammary (IM), and clavicular (CL) basins were monitored in all patients. MOVA was compared with the anterior view for sentinel node identification. Age, weight, breast size, method of biopsy, interval after biopsy, and primary tumor location were evaluated for their effects on sentinel node localization and transit times from injection to arrival at the sentinel nodes. RESULTS: Seventy-six lymphoscintigrams were obtained for 75 patients. AX sentinel nodes were revealed in 75 (99%) cases. IM or CL sentinel nodes were found in 19 (25%) cases and were not related to tumor location; exclusive IM drainage was present in 1 (1%) case. Identification of AX sentinel nodes was equivalent with MOVA and anterior views in 18 (24%) patients, was better with MOVA in 20 (26%) patients, and was accomplished only with MOVA in 38 (50%) patients. Median transit time was 17.5 min (range, 1 min to 18 h) after injection, and larger breast size was associated with increased transit time. No effect of age, weight, biopsy method, interval from biopsy, or tumor location on transit time was found. CONCLUSION: Use of MOVA can improve identification of AX sentinel nodes. Although AX drainage is the predominant pattern, a tumor in any portion of the breast can drain to IM sentinel nodes. Transit time was influenced by breast size. Overall short arrival times with this technique allow sentinel lymph node dissection to be performed on the same day as lymphoscintigraphy.     

Lymphatic mapping in patients with breast carcinoma: reproducibility of lymphoscintigraphic results

PURPOSE: To evaluate the reproducibility of lymphoscintigraphic results in assessment of the location and number of sentinel nodes in patients with breast cancer. MATERIALS AND METHODS: Twenty-five patients with breast cancer were prospectively enrolled in this study. Lymphoscintigraphy was performed after intratumoral injection of about 130 MBq of technetium 99m nanocolloid. Anterior and lateral images were obtained 20 minutes and 2 and 4 hours after injection. The following day, scintigraphy was repeated after a second injection of the radiolabeled colloid in an identical fashion and was preceded by acquisition of a starting image. Two observers evaluated the paired images independently, and count rates were calculated from the images. Correlation coefficient and Bland-Altman methods were used to analyze the paired count rates. RESULTS: At least one sentinel node was visualized at lymphoscintigraphy in all 25 patients. Drainage to the axilla was observed in 17 patients; drainage to the axilla and extraaxillary basins, in seven patients; and drainage exclusively to extraaxillary sentinel nodes, in one patient. The second scintigraphic study revealed the same drainage pattern in all 25 patients (reproducibility, 100%; 95% CI: 86%, 100%). The Pearson correlation coefficient of the paired count rates was 0.54 (P <.001). Count rates at repeat scintigraphy were 23%-417% of the count rates at first scintigraphy in 95% of cases. CONCLUSION: Results of lymphoscintigraphy for lymphatic mapping in breast cancer are highly reproducible for assessment of the number of sentinel nodes.     

Evaluation and localization of lymphatic drainage and sentinel lymph nodes in patients with head and neck melanomas by hybrid SPECT/CT lymphoscintigraphic imaging

In patients with head and neck tumors, preoperative lymphoscintigraphy can be used to map lymphatic drainage patterns and identify sentinel lymph nodes. However, it is very difficult to determine the exact locations of head and neck sentinel nodes on preoperative lymphoscintigraphy without the use of anatomic landmarks. Lymph nodes in the head and neck are grouped into 7 regions, or levels, on the basis of anatomic landmarks. In patients undergoing standard lymphoscintigraphy, obtaining lateral marker images that show important anatomic landmarks can help with the localization of sentinel nodes. However, technical problems often render marker images of little or no use. Hybrid SPECT/CT lymphoscintigraphic imaging facilitates the localization of sentinel nodes by reliably showing the relationships between sentinel nodes and important anatomic structures. After reading this article, the reader should understand the lymph node level classification system for head and neck melanomas, be able to describe the technique used for the imaging of sentinel nodes in the head and neck region, and be able to demonstrate how SPECT/CT lymphoscintigraphic imaging can enable precise sentinel node localization and thus help to ensure minimal dissection.     

Influence of fast lymphatic drainage on metastatic spread in cutaneous malignant melanoma: a prospective feasibility study

The concept of sentinel lymph node biopsy in cutaneous malignant melanoma is widely established. Preoperative cutaneous lymphoscintigraphic mapping is a reliable method for identifying the nodal basins at risk of metastases in melanomas. In this prospective study we investigated the correlation between the scintigraphic appearance time and the metastatic involvement of sentinel lymph nodes. In 276 malignant melanoma patients (137 women, 139 men; age 16-93 years), dynamic and static lymphoscintigraphy was performed after strict intracutaneous application of technetium-99m nanocolloid (40-150 MBq; 0.05 ml/deposit) around the tumour or biopsy scar. Analysis of dynamic scans primarily focussed on the appearance time of sentinel lymph nodes. Sentinel lymph node visualisation 20 min as slow drainage. Fast lymphatic drainage was found in 236 patients, of whom 34 (14.4%) had sentinel lymph node metastases. Twenty-two patients showed hybrid (fast and slow) lymphatic drainage, and eight (36.4%) of them had sentinel lymph node metastases. Seven of the latter demonstrated fast lymphatic drainage, while one showed one positive sentinel lymph node with fast and another with slow drainage. The melanomas of 18 patients demonstrated exclusively slow lymphatic drainage, in all cases without sentinel lymph node metastases. This prospective study indicates that the scintigraphic appearance time of sentinel lymph nodes seems to be a clinically relevant factor for prediction of metastatic spread of cutaneous malignant melanoma. Larger numbers of patients need to be examined to truly assess the benefit of the scintigraphic appearance time compared with other predictors of sentinel lymph node tumour positivity.     

Successful internal mammary visualization with periareolar injections of Tc-99m antimony sulfur colloid in sentinel node breast lymphoscintigraphy

PURPOSE: The subareolar and periareolar injection techniques result in higher detection rates and do not require tumor localization in impalpable lesions when compared with the peritumoral technique. One of the main criticisms, however, is the widely reported inability to detect internal mammary nodes. This contrasts with our clinical experience using Tc-99m antimony sulfur colloid, in which internal mammary nodes are commonly seen. METHODS: A retrospective analysis of 241 patients over 38 months was performed to investigate the ability of our periareolar injection technique to detect internal mammary lymph node drainage in breast cancer sentinel node lymphoscintigraphy. Four injections of 5 to 10 MBq (0.14-0.27 mCi) Tc-99m antimony sulfur colloid were administered on the day of surgery followed by massage and imaging. The radioisotope was suspended in 0.1 mL with a 0.5-mL air lock. Each injection was performed over 2 seconds with a 25-gauge needle at a depth of 1.1 to 1.3 cm. Patients whose records could not be retrieved or who underwent an injection technique apart from periareolar or peritumoral were removed from the analysis. RESULTS: One hundred thirty-three patients underwent the periareolar technique, 72 patients underwent the peritumoral technique, and 36 patients were excluded from the analysis. Internal mammary drainage was seen in 24 of 133 (18.0%) patients, of which 12 (9%) were seen only in the internal mammary chain. This is much higher than previous studies quoting 0.0% to 4.3% and is similar to previously reported rates using the peritumoral technique. CONCLUSIONS: Our periareolar injection technique using Tc-99m antimony sulfur colloid is able to detect internal mammary lymph nodes in at least 18.0% of patients.     

Impact of internal mammary sentinel node imaging in breast cancer

A 28-year-old woman underwent mammary lymphoscintigraphy for evaluation of the sentinel node status of a small infiltrating ductal carcinoma in the central, lower, and outer quadrant of the left breast confirmed by biopsy. The patient was scheduled for lumpectomy and sentinel node biopsy. Lymphoscintigraphy showed increased uptake at two sites of the peritumorally injected tracer (60 MBq; 1.6 mCi rhenium sulfur nanocolloid) in internal mammary nodes, two of which were located most proximal to the tumor and related to the tumor by two distinct lymphatic ducts. An axillary lymph node was also detected. At surgery, the gamma probe confirmed the location of all the hot spots, and four nodes were harvested: one axillary, two first internal mammary nodes in the third intercostal space, and one internal mammary node in the second intercostal space. Histologic analysis revealed that the axillary sentinel node was free of disease, but the two first intramuscular sentinel nodes were metastatic. The second-echelon internal mammary node above the sentinel nodes (second intercostal space) was free of disease. This case shows the benefit of imaging all the drainage pathways of a breast tumor and retrieving nonaxillary lymph nodes, which may be the only positive nodes. As a result of the findings, the patient's prognosis may be altered and the subsequent therapeutic approach may be modified. Although exclusive involvement of the internal mammary chain is well established and relatively rare (occurring in approximately 5% of cases), it is important to remember that the axillary status of a breast tumor is not the only major prognostic factor.     

Lymphatic mapping in early stage breast cancer: comparison between periareolar and subdermal injection

The combination of preoperative lymphatic mapping with intra-operative probe detection is becoming the standard procedure for identifying tumour lymphatic spread at the time of initial treatment in breast cancer. There are a number of identification techniques for sentinel lymph nodes, but the concordance of the results of a sentinel lymph node biopsy with axillary lymph node dissection did not vary significantly among them. Periareolar (p.a.) injection of tracer is a new procedure specifically studied to overcome some limitations of other techniques; in two groups of patients with early breast cancer we compared the periareolar with the subdermal technique. One hundred and fifty biopsy proven breast cancer patients were consecutively enrolled in this study. This population was divided into two groups: (1) group A, including 100 cancers; lymphatic mapping was performed by s.d. injection of both blue dye and radiotracer; and (2) group B, including 50 cancers; lymphatic mapping was performed with a combination of blue dye injected p.a. and radiotracer injected s.d. For group A, with both techniques we identified one or more SLNs in 100/100 tumours; blue dye detected the SLNs in 99/100 cancers (99%), lymphoscintigraphy in 93/100 cancers (93%). The concordance rate was 92%. For group B, with both techniques we identified one or more SLNs in 49/50 cancers (98%); blue dye detected the SLNs in 48/50, lymphoscintigraphy in 46/50 cancers (92%). The concordance rate was 92%. In the present study p.a. and s.d. injection of blue dye give similar and comparable results. The periareolar technique is simpler and has several advantages over the subdermal technique.     

Breast cancer with metastatic invasion of the sentinel lymph node in an internal mammary chain and with axillary chains free of tumor lesionS

The lymphoscintigraphy is a widely accepted procedure to detect the sentinel node in breast cancer. This is a case report of a 45 year old woman diagnosed of breast cancer who was referred to the nuclear medicine facility to perform the sentinel node detection procedure. The lymphoscintigraphy prior to surgery shows a double pathway in the tracer migration: one going to the axillary area and the second to the internal mammary chain and shows hot spots that represent the sentinel nodes. After surgical removal of those nodes, the pathological analysis report indicated tumor infiltration in the internal mammary chain sentinel node with all axillary nodes free of malignant cells. The aim of this report is to emphasize the importance of performing a pathological analysis of all the sentinel nodes detected in lymphoscintigraphy.     

The hidden sentinel node in breast cancer

The purpose of this study was to analyse the occurrence of non-visualisation during preoperative lymphoscintigraphy for sentinel node identification in breast cancer. Preoperative lymphoscintigraphy was performed in 495 clinically node-negative breast cancer patients (501 sentinel node procedures) after injection of technetium-99m nanocolloid. Anterior and prone lateral (hanging breast) planar images were obtained a few minutes and 4 h after injection. The sentinel node was intraoperatively identified with the aid of patent blue dye and a gamma-ray detection probe. A sentinel node was visualised on the 4-h images in 449 of 501 procedures (90%). This visualisation rate improved from 76% to 94% during the study period. Delayed imaging (5-23 h) in 19 patients whose sentinel nodes failed to show, resulted in visualisation in four of them. A repeat injection of radiocolloid in 11 patients revealed a sentinel node in six. In the end, the visualisation rate was 92%. The sentinel node was surgically retrieved in 24 of the remaining 42 patients with non-visualisation (57%). Sentinel nodes that were visualised were tumour-positive in 38% and non-visualised sentinel nodes were involved in 50% (chi2, P=0.17). In a multivariate regression analysis, scintigraphic non-visualisation was independently associated with increased patient age (P<0.001), decreased tracer dose (P<0.001) and increased number of tumour-positive lymph nodes (P=0.013). The use of a sufficient amount of radioactivity (at least 100 MBq) is recommended for lymphatic mapping in breast cancer, especially in elderly women. Delayed imaging and re-injection of the radioactive tracer increase the visualisation rate. The non-visualised sentinel node can be identified intraoperatively in more than half of the patients.     

Identification of bilateral breast sentinel lymph nodes draining primary melanoma of the back by preoperative lymphoscintigraphy and intraoperative mapping.

A 30-year-old white woman with a primary malignant melanoma of her right back at the Sappey line, 4 cm from the midline at the L2 level, underwent preoperative lymphoscintigraphy and intraoperative mapping of the sentinel lymph node using lymphazurin injection at the primary site and a hand-held gamma probe. Lymphoscintigraphy showed one sentinel lymph node in each breast and another one in the right axilla. These three sentinel lymph nodes were accurately identified using a hand-held gamma probe during operation. An additional sentinel and one nonsentinel lymph node from the right axilla were harvested. All four sentinel lymph nodes were blue and showed significantly elevated radioactivity compared with background. Histologic analysis showed that all these lymph nodes were negative for metastatic melanoma. She has been followed for a period of 26.7 months since her selective sentinel lymphadenectomy and has been free of disease to date. This case illustrates the importance of preoperative lymphoscintigraphy in identifying in-transit sentinel lymph nodes in both breasts in addition to the clinically predictable sentinel lymph node(s) in the right axilla.